Emotional dysregulation in endometriosis women with cyclical and non-cyclical chronic pelvic pain

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One of the main clinical problems of endometriosis is chronic pelvic pain (CPP), which considerably affects the patients’ quality of life. Patients with endometriosis may, cyclically or non-cyclically (80% of cases) experience CPP. High levels of anxiety and depression have been described in patients with endometriosis related to CPP; however, this has not been evaluated in endometriosis women with different types of CPP. Methods: This work aimed to determine if there are differences in emotional dysregulation in patients with cyclical and non-cyclical CPP. 49 women diagnosed with endometriosis presenting cyclical and non-cyclical CPP answered several batteries made up of Mini-Mental State Examination, Visual Analog Scale, Beck´s Depression Inventory, State Trait-Anxiety Inventory, and Generalized Anxiety Inventory. Results: We observed that patients with non-cyclical CPP exhibited higher levels of depression and anxiety (trait-state and generalized anxiety) than patients with cyclical pain. No differences were observed in pain intensity, but there was a higher probability of developing emotional dysregulation (anxiety or depression) in patients with non-cyclical CPP. No differences were observed in cognitive impairment. Conclusions: Our data suggest that patients with non-cyclical CPP present a higher emotional dysregulation than those with cyclical pain. Chronic pelvic pain anxiety depression endometriosis menstrual cycle emotions Figures Figure 1 Introduction Endometriosis is a disease distinguished by a tissue similar to the lining of the uterus growing outside it causing pain and infertility 1 , 2 . 50% of infertile women exhibit endometriosis worldwide. Therefore, it is considered the most common gynecological disease in women of reproductive age and in perimenopausal women 3 . In Mexico, epidemiological reviews have estimated an endometriosis incidence of 34.5% in women diagnosed with primary and secondary infertility at the National Institute of Perinatology 4 . Endometriosis symptoms are infertility, dyspareunia, heavy menstrual bleeding, chronic fatigue, fibromyalgia, migraine, and central sensitization syndrome 5 – 7 . However, the main clinical problem of endometriosis is chronic pelvic pain (CPP), which is defined as intermittent or constant pain in the lower abdomen or pelvis of at least six months, not occurring exclusively with menstruation or intercourse, and not associated with pregnancy 8 , 9 . One of the most common causes of CPP in women is endometriosis (24–40%). Other associated conditions such as interstitial cystitis/bladder pain syndrome, chronic urinary tract infections, vulvodynia, irritable bowel syndrome, and inflammatory bowel disease may be comorbid with endometriosis 10 – 12 . CPP is a persistent and debilitating condition associated with high costs and morbidity. Significant costs are associated with CPP, including absences from work, increased surgeries, and heavy burden to the healthcare system 13 . CPP and infertility in women with endometriosis are associated with high levels of stress and uncertainty, reducing their quality of life and making challenging the performance of daily activities and the development of interpersonal relationships 14 , 15 . Additionally, the difficulty experienced by these women from the onset of the first symptoms until diagnosis increases the probability of presenting emotional alterations. The average time between the onset of symptoms and the seeking help is from 3.7 to 5.7 years, extending up to 8 years for timely diagnosis 7 , 16 , 17 . The mechanisms by which CPP is generated in endometriosis have not been clearly defined. However, it occurs near endometriotic glands, and blood vessels in peritoneal endometriotic lesions innervated by sensory A delta, sensory C, cholinergic and adrenergic nerve fibers 18 . Nerve fiber densities are increased in the myometrium of women with endometriosis compared with those presented in women without this pathology 19 , 20 . Although these nerve fibers may play an essential role in the mechanisms of pain generation in endometriosis, the emotional dysregulation can mediate the nociceptive experience by brain regions such as the anterior insula and the anterior cingulate cortex 21 , 22 . Variable and broad symptoms and social implications of endometriosis have been considered disruptive to mental health, exhibiting high anguish, anxiety, depression, and chronic stress 23 – 26 . It has been described that the presence of CPP affects mental health 14 , regardless of endometriosis stage or type 27 , and it did not always decrease after medical treatment or surgery. Patients with endometriosis may experience CPP cyclically or non-cyclically (80% of cases) defined as non-menstrual pain 28 , 29 ; however, whether there is a difference in levels of anxiety and depression between these two patient groups has not been evaluated. Therefore, it is not known how different CPP affects the emotional state of women with endometriosis. This study aimed to determine if there are differences in emotional dysregulation in patients with cyclic and non-cyclic CPP. Methods Design of the Study We conducted a transversal study at the National Institute of Perinatology (INPer, Neuroscience Department, Mexico City) from January 2019 to March 2020. Approval from the Institution Ethical and Scientific Committee was obtained before the beginning of the study (reference number: INPer, 2019-1-51). Women with endometriosis were invited to participate in the study when coming to their gynecology interview at Department of Gynecology at INPer. Patients who voluntary participated in the study were requested to sign a written informed consent. During the initial interviews at the Gynecology and Neuroscience Departments, we assessed the patients’ eligibility according to the inclusion criteria. Participants gynecological, sociodemographic, and psychological characteristics were recorded in a database. Participants Patients recruited into the study were attended at the Gynecology Department in the INPer. The recruited population comprised women from 18 to 52 years old with a diagnosis of endometriosis (by laparoscopic or magnetic resonance) and CPP for at least 1 year. The medical staff carried out a complete clinical evaluation and an analysis of sociodemographic variables was done, including marital status, education level, and working status. Participants were asked to complete self-reported questionnaires used to measure cognitive impairment, the intensity of pelvic pain, general discomfort, depression, and anxiety: Mini-Mental State Examination (MMSE), Visual Analog Scale (VAS), Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI) and Generalized Anxiety Disorder Screener (GAD). 54 patients were recruited, but 5 were discarded for not completing evaluations. 49 participants were included in the study and divided into two groups according to the type of CPP they experienced. If the patient suffered from CPP only during her menstrual period, she was classified in the cyclical CPP group (n=21), if the patient presented persistently CPP regardless of the menstrual phase, she was classified in the group of non-cyclical CPP group (n=28). Instruments The Mini-Mental State Examination (MMSE) is a test used to detect mild cognitive impairmentthrough tests of orientation, memory, attention, calculation, and language. If the score is ≤ 24, probable cognitive impairment is suspected and if it is > 24, the result was "without cognitive impairment" 30 . Wong-Baker FACES® Pain Rating Scale is a visual analog scale (VAS) that self-reported the intensity of CPP. The scale is made up of six faces drawn with ratings from 0 to 10, where 0 is equivalent to the minimum pain and 10 to the maximum pain that have experienced 31 . Beck Depression Inventory (BDI) is a 21-item measure of depression equivalent to the Diagnostic and Statistical Manual of Mental Disorders (DSM) symptoms of depression 32 . Patients chose their responses on a 0-3 Likert-type scale. BDI scores can range from 0 to 63 with the following cut- offs: 0-13, minimally depressed; 14-19, mildly depressed, 20-28, moderately depressed, and 29-63, severely depressed 33,34 . State-Trait Anxiety Inventory (STAI) is used to measure two different dimensions of anxiety: State Anxiety Scale evaluated the current state of anxiety, asking how patients feel “right now”; and Trait Anxiety Scale evaluated relatively stable aspects of “anxiety proneness” 35 . Scores of both scales range from 20 to 80. Scores between 20 and 31 indicated minimal anxiety, 32 to 43 mild anxiety, 44 to 55 moderate anxiety, 56 to 67 severe anxiety, and 60 to 80 maximum anxiety 36 . Generalized Anxiety Disorder Screener (GAD) is a 7-item self-report for screening of Generalized Anxiety Disorder which are rated on a 4-point Likert-type indicating symptom frequency, ranging from 0 (not at all sure) to 3 (nearly every day), yielding a value in the response range from 0 to 21 points. Higher scores indicate higher levels of GAD symptoms 37 . Statistical analysis Demographic parameters and sociomedical conditions were expressed as mean ± SD or N (%). Inferential analysis was performed with a chi-square (nominal variables), Mann-Whitney U (ordinal variables), and Student’s t-test for independent samples (scalar variables) to compare the difference between groups. Relative risk estimation was performed to determine the association between non-cyclical and cyclical CPP with probability of presenting emotional dysregulation. Statistical analyzes were performed with SPSS v.24.0 software (Armonk, New York: IBM Corp). For all statistical analyses, p < 0.05 was considered significant. Results Demographics characteristics Table 1 shows the sociodemographic characteristics of endometriosis women with cyclical (n=21) and non-cyclical CPP (n = 28). There were no differences in age, years of study, working status and marital status between the two groups. However, results indicate that only 23.8% of women with cyclic pain and 53.5% with non-cyclical pain were married or cohabiting. Table 1 Sociodemographic characteristics of endometriosis women with CPP. Participants Cyclical pain Non-cyclical pain p-value n=49 n=21 n=28 Age Mean (SD) Mean (SD) .80 35.2 (6.9) 34.7 (6.47) Marital status N (%) N (%) .10 Never married 15 (71.4) 10 (35.7) Married 3 (14.3) 9 (32.1) Divorced 1 (4.8) 3 (10.7) Cohabiting 2 (9.5) 6 (21.4) Years of study Mean (SD) Mean (SD) .40 14.4 (3.4) 15.1 (3.13) Working status N (%) N (%) .96 Employee 5 (23.8) 5 (17.9) Unemployed 2 (9.5) 4 (14.3) Home labor 5 (23.8) 7 (25) Commerce 3 (9.5) 4 (14.3) Profession 4 (19.4) 6 (21.4) Study 1 (4.8) 2 (7.1) The parametric t-test was used to detect statistical differences between demographic measures age, years of study. The chi-square test was used to determine differences in marital status, working status between women with cyclical and non-cyclical pain. n=49. Medical characteristics of patients are described in Table 2. The percentage of nulliparous women is higher in women with non-cyclical CPP (78.6%) than in cyclical CPP women (45.6%). In both cases about 60% of patients report disabling pain for about 11 years and more than 70% of all women described at least another symptom associated with endometriosis. Most patients in both groups have received at least one surgery to manage symptoms including cleaning of endometrial focuses by laparoscopy, which was the most common surgery in these patients. Additionally, all women reported consumption of some drug for the endometriosis symptoms, mainly non-steroidal anti-inflammatory drugs (NSAIDs). This consumption was significantly higher in women with non-cyclical pain (92.9 %) compared with cyclical CPP women (71.4 %). Differences in comorbidities were found, the percentage of women with hypothyroidism and myomatosis was higher in women with cyclical CPP compared to women with non-cyclical CPP. No differences were found in disabling CPP perception, years reporting disabling pain, other presenting symptoms, previous surgery endometriosis, or disruptions, between women with cyclical and non-cyclical pain. Table 2 Medical conditions of endometriosis women with CPP. Cyclical pain Non-cyclical pain p-value Parity a N (%) N (%) Nulliparous 10 (45.6) 22 (78.6) * .02 ≥1 11 (52.4) * 6 (21.4) .02 Infertility diagnosis 0 2 (7.1) .21 Disabling CPP perception N (%) N (%) .61 Yes 12 (57.1) 18 (64.3) No 9 (42.9) 10 (35.7) Years reporting disabling CPP Mean (SD) Mean (SD) .69 10.8 (1.9) 11.6 (1.5) Other symptoms a N (%) N (%) No other b 7 ( 33.3) 7 (25) .52 Menorrhagia 6 (28.6) 14 (50) .13 Dyspareunia 7 (33.3) 10 (35.7) .86 Widespread pain 2 (9.5) 4 (14.3) .61 Amenorrhea 2 (9.5) 3 (10.7) .89 Chronic fatigue 1 (4.8) 4 (14.3) .27 Inflammation 4 (19.0) 1 (3.6) .07 Rectal tenesmus 0 2 (7.1) .21 Dysuria 1 (4.8) 1 (3.6) .83 Premenstrual dysphoria 1 (4.8) 0 .24 Subinfertility 1(4.8) 0 .73 Previous endometriosis surgery N (%) N (%) .84 0 6 (28.6) 8 (28.6) 1 9 (42.9) 10 (35.7) ≥2 6 (28.6) 10 (35.7) Surgery for endometriosis a N (%) N (%) Endometrial focuses 5 (23.8) 13 (46.4) .52 Oophorectomy 6 (28.6) 5 (17.9) .37 Hysterectomy 3 (14.3) 5 (17.9) .73 Colectomy 2 (9.5) 1 (3.6) .39 Pharmacotherapy a N (%) N (%) NSAIDs c 15 (71.4) 26 (92.9) * .04 Hormones 7 (33.3) 8 (28.6) .72 Antispasmodic 1 (4.8) 3 (10.7) .45 Anxiolytics 2 (9.5) 2 (7.1) .76 Opioid analgesic 2 (9.5) 1 (3.6) .09 Cannabis 0 2 (7.1) .21 Disruptions a N (%) N (%) None 9 (42.9) 5 (17.8) .11 Work/School 5 (23.8) 10 (35.7) .37 Relationship 6 (28.6) 8 (28.6) 1 Next surgery 5 (23.8) 6 (21.4) .84 Social 3 (14.3) 5 (17.9) .73 Desire to be a mother 3 (14.3) 4 (14.3) 1 Family 0 5 (17.9) .07 Economy 1 (4.8) 1 (3.6) .83 Comorbidities a N (%) N (%) None 10 (47.6) 19 (67.9) .15 Polycystic ovary 3 (14.3) 3 (10.7) .70 Hypothyroidism 3 (14.3) * 0 .03 Myomatosis 3 (14.3) * 0 .03 Adenomyosis 2 (9.5) 1 (3.6) .39 Overactive bladder 2 (9.5) 0 .09 Obesity 0 1 (3.6) .38 Anemia 0 1 (3.6) .38 Heart disease 1 (4.8) 0 .24 The parametric t-test was used to detect statistical differences between years reporting disabling CPP. The chi-square test was used to determine differences disabling CPP, parity, other presenting symptoms, previous surgery for endometriosis, pharmacotherapy, disruptions, and comorbidities between women with cyclical and non-cyclical pain. n= 49; *p<0.05. (a) Different options can be associated in the same patient. (b) No other symptoms of endometriosis besides CPP. (c) NSAIDs, Non-steroidal anti-inflammatory drugs. To determine differences in global scores psychometric scales applied between endometriosis patients with cyclical and non-cyclical CPP, a normal distribution of the results was corroborated with the Shapiro wilk test for n ≥ 30 and Levene's test showed equality of variances. Then, the global scores of each scale were analyzed using a Student's t test for independent samples. The global scores obtained in depression, anxiety as a trait and state, and generalized anxiety were higher in women with non-cyclical chronic pain than in those with cyclical pain (Table 3). Student's t test for cognitive impairment could not be calculated because the standard deviation of both groups was equal to 0. Table 3 Cognitive impairment, pain perception, and emotional dysregulation global scores in endometriosis women with cyclical and non-cyclical pain. Type of chronic pelvic pain Cyclical Non-cyclical p-value Cognitive impairment 28.80 (1.28) 28.35 (1.06) .11 Pain intensity 7.90 (2.79) 8.85 (1.48) .13 Depression 11.14 (2.42) 17.46 (1.92) * .04 Trait anxiety 37.42 (3.23) 47 (2.02) * .01 State anxiety 39.33 (2.52) 47.35 (1.89) * .02 Generalized anxiety 5.14 (1.08) 8.46 (1.05) * .03 Table shows the mean ± SD, n=49, *p<0.05. To determine differences in pain perception and emotional dysregulation between patients with cyclical and non-cyclical CPP according to the clinical classification of each psychometric scales, a Mann-Whitney U test was performed. Most patients with non-cyclical pelvic pain exhibited mild state anxiety (α = 0.007) and depression from mild to severe (α = 0.018) compared to women with cyclical CPP that presented a lower emotional affectation (Figure 1). No differences were observed in pain intensity, anxiety as a trait or generalized anxiety according to the clinical classification. However, it was found that 70% of endometriosis women with cyclical CPP and more than 90% of the non-cyclical population reported severe to maximum pain; and more than 60% of patients with noncyclic pain presented mild to severe generalized anxiety. A relative risk estimation was performed to determine the association between non-cyclical or cyclical CPP and the probability of presenting depression or anxiety as risk factors. Results demonstrated a significant relative risk (> 1) in depression (2.5), trait-state anxiety (2.25, 2.85, respectively), and generalized anxiety (2.0) in patients with non-cyclical pain. Relative risk of patients with cyclical chronic pain was not significant (Table 4). Table 4 Relative risks of patients with cyclical and non-cyclical pain Type of chronic pain Depression Trait anxiety State anxiety Generalized anxiety Ciclycal 0.40 (0.13-1.20) 0.44 (0.17-1.12) 0.35 (0.6-0.77) 0.54 (0.28-1.04) Non-cyclycal 2.5 (0.82-7.54) * 2.25 (0.88-5.71) * 2.85 (1.29-6.25) * 2.0 (0.96-3.45) * Table shows relative risk scores and SD, asterisk (*) represents a significant relative risk (> 1). n=49. Discussion Endometriosis is a long-term, disabling medical condition that affects the quality of life and mental health associated with CPP. Patients with endometriosis may experience CPP in a cyclical manner such as dysmenorrhea or in a noncyclical manner defined as non-menstrual pain. Several reports suggest that chronic experience of pain increases emotional dysregulation 38 – 40 and that psychiatric disorders are more common among women with endometriosis 41 – 44 , however, differences in emotional dysregulation based on CPP experience in women with endometriosis had not been explored. Therefore, the objective of this study was to determine if there are differences in the levels of emotional dysregulation in patients with cyclical and non-cyclical CPP. This is one of the few studies carried out in Latin America where specialized endometriosis care centers are very limited 45 , 29 High levels of depression and anxiety were found in both groups of patients with CPP, which coincided with previous studies 41 – 44 , however, the present work is the first one in demonstrating higher global scores in depression, anxiety as a trait and state, and generalized anxiety in women with non-cyclical CPP. In addition, more women with endometriosis experiencing non-cyclic CPP suffered from mild to severe depression and mild state anxiety compared to women experiencing cyclical pain. Therefore, emotional attention of these women is imperative to improve their quality of life. Relative risk estimation associated with pain intensity determined a higher probability of developing depression, trait-state anxiety, and generalized anxiety in patients with non-cyclical pain. In fact, the risk of presenting emotional disturbances is doubled in the group of women with noncyclic pain than in those with cyclical pain, which gives us clinically significant and relevant data for the diagnosis and management of these patients 46 , 47 . Pain intensity was assessed using the VAS, since it has been shown to be effective for most patients with endometriosis (64%) during the painful experience and indeed, one month after the experience 48 . However, no statistically significant differences were found in intensity of pain between CPP groups. In both cases most patients report severe to maximum pain and perceive it as a disabling pain for about a decade, which could significantly affect their quality-of-life 49 . The relationship between reports of pain and physical pathology is still debated. Authors suggest a complete evaluation of the pain considering location, duration, sensory and affective description, functional status in daily activities 50 ; and the hours or sleep disturbances derived from pain 23 . Besides, Api 51 highlights that other symptoms of endometriosis such as painful intercourse or dyspareunia can mediate the intensity of CPP; however, in this study no differences were found in other symptoms of endometriosis between patients with cyclical and non-cyclical pain. For the management of endometriosis symptoms, all the patients reported drug use, mainly analgesics. Because cognitive impairment is common in patients with chronic pain for excessive use of analgesics including opioids, increased vulnerability to endocrine disrupting chemicals, and age-related cognitive decline 52 – 54 , MMSE test was applied. However, no cognitive impairment was found in women with endometriosis using MMSE. Nevertheless, cognitive impairments were reported by Wassink, 55 through EGG and event-related potentials in these patients. It is recommended to explore specific cognitive functions with neuropsychological batteries to improve rehabilitation for future studies 56 . In this study, most patients reported disruptions associated with symptoms of endometriosis, at work, relationships and family. In addition, it was observed that most women with cyclical pain had not been married, and most women with non-cyclical pain do not have children. Low social support and family networks must maintain depressive and anxious states 57 – 58 , so women with endometriosis may be more vulnerable to living with chronic emotional dysregulation, which is associated with low quality of life 45 . Marital status and number of children are not predictors of emotional well-being in midlife in women, but rather the quality of relationships 59 , 60 . Intensity of pain and emotional dysregulation in women with endometriosis can be mediated by psychosocial variables such as emotional suppression, pain catastrophism, personality, and a passive coping style, which can also affect patients’ interactions 61 – 63 . Different comorbid conditions have been implicated in CPP in endometriosis, such as pelvic floor tenderness, painful bladder syndrome, sexual assault, higher body mass index, current smoking, physical activity, depression, and anxiety 64 , 65 . This is the first study that describes differences in emotional dysregulation according to the type of CPP experienced by patients with endometriosis. Therefore, continued research is required to validate these psychosocial factors and determine if any of them is potentially modifiable for improving the quality of life of women with endometriosis. Conclusions Our data suggest that patients with non-cyclical CPP present higher levels of depression and anxiety than those with cyclical pain, and that non-cyclical CPP may make patients more vulnerable to developing emotional dysregulation. Abbreviations CPP chronic pelvic pain; INPer, National Institute of Perinatology; MMSE, Mini-Mental State Examination; VAS, Visual Analog Scale; BDI, Beck Depression Inventory; DSM, Diagnostic and Statistical Manual of Mental Disorders; STAI, State-Trait Anxiety Inventory; GAD, Screener; NSAIDs, Non-steroidal anti-inflammatory drugs. Declarations Ethics approval and consent to participate We received the approval of the clinical study from the head of the Ethical and Research Committee of National Institute of Perinatology, Isidro Espinosa de los Reyes, (Montes Urales # 800, Col Lomas de Virreyes, 11000, CD MX, Mexico) with the project No. 20191-51. The written Informed Consent was also obtained from all participants recruited in the present study All methods were performed in accordance with the relevant guidelines and regulations in compliance with the Helsinki Declaration. Consent for publication Not applicable Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due institutional policies but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing financial and non-financial interests that could influence the publishing of the final version of the manuscript. Funding This study was supported by INPer Project No. 2019-1-51, and by CONACYT for the first author's doctoral grant, No. 749741. Authors’ contributions MPMR designed and conducted the study. DCRL wrote the body of the manuscript. ICA and BDT were major contributors in reviewing the data and body of the manuscript and amending several areas of the manuscript. OPCO, BSR, AOO, JRST, GCB, LFEP conducted the clinical intervention in women with endometriosis to assesses the recruitment of patients into the study. DCRL and MPMR applied and scored the psychometric instruments to the participants. DCRL, MPMR and JMSP contributed to the statistical analysis of data. Acknowledgements This study was supported by INPer Project No. 2019-1-51, and by CONACYT for the first author's doctoral grant, no. 749741. References Surrey E, Carter CM, Soliman AM, Khan S, Di Benedetti DB, Snabes MC. Patient-completed or symptom-based screening tools for endometriosis: a scoping review. 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J Psychosom Res. 2019;124:109756. doi: 10.1016/j.jpsychores.2019.109756. Mechsner S. Endometriosis, an Ongoing Pain-Step-by-Step Treatment. J Clin Med. 2022;11(2):467. doi: 10.3390/jcm11020467. Nunnink S, Meana M. Remembering the pain: accuracy of pain recall in endometriosis. J Psychosom Obstet Gynaecol. 2007;28(4):201-8. doi: 10.1080/01674820701388781. Olliges E, Bobinger A, Weber A, Hoffmann V, Schmitz T, Popovici RM, Meissner K. The Physical, Psychological, and Social Day-to-Day Experience of Women Living With Endometriosis Compared to Healthy Age-Matched Controls-A Mixed-Methods Study. Front Glob Womens Health. 2021; 2:767114. doi: 10.3389/fgwh.2021.767114. Cid J C, Acuña B J, de Andrés A J, Díaz J L, Gómez Caro A. ¿Qué y cómo evaluar al paciente con dolor crónico? evaluación del paciente con dolor crónico. Rev Méd Clín Condes. 2014;25(4):687-97. Api M, Boza AT, Kayatas S, Eroglu M. Effect of Surgical Removal of Endometriomas on Cyclic and Non-cyclic Pelvic Pain. Int J Fertil Steril. 2015; 9(2):183-8. doi: 10.22074/ijfs.2015.4252. Altiparmak B, Güzel Ç, Gümüş Demirbilek S. Comparison of Preoperative Administration of Pregabalin and Duloxetine on Cognitive Functions and Pain Management After Spinal Surgery: A Randomized, Double-blind, Placebo-controlled Study. Clin J Pain. 2018;34(12):1114-1120. doi: 10.1097/AJP.0000000000000640 Kahn LG, Philippat C, Nakayama SF, Slama R, Trasande L. Endocrine-disrupting chemicals: implications for human health. Lancet Diabetes Endocrinol. 2020;8(8):703-718. doi: 10.1016/S2213-8587(20)30129-7. Sörös P, Bantel C. Chronic noncancer pain is not associated with accelerated brain aging as assessed by structural magnetic resonance imaging in patients treated in specialized outpatient clinics. Pain. 2020;161(3):641-650. doi: 10.1097/j.pain.0000000000001756. Wassink K, De Blasio FM, Fogarty JS, Cave AE, Love S, Armour M. Neuronal Correlates of Cognitive Control Are Altered in Women With Endometriosis and Chronic Pelvic Pain. Front Syst Neurosci. 2020; 14:593581. doi: 10.3389/fnsys.2020.593581. Halicka M, Vittersø AD, Proulx MJ, Bultitude JH. Neuropsychological Changes in Complex Regional Pain Syndrome (CRPS). Behav Neurol. 2020 14; 2020:4561831. doi: 10.1155/2020/4561831. Gariépy G, Honkaniemi H, Quesnel-Vallée A. Social support and protection from depression: systematic review of current findings in Western countries. Br J Psychiatry. 2016; 209(4):284-293. doi: 10.1192/bjp.bp.115.169094. Bedaso A, Adams J, Peng W, Sibbritt D. The relationship between social support and mental health problems during pregnancy: a systematic review and meta-analysis. Reprod Health. 2021; 18(1):162. doi: 10.1186/s12978-021-01209-5. Earle JR, Smith MH, Harris CT, Longino CF Jr. Women, marital status, and symptoms of depression in a midlife national sample. J Women Aging. 1998;10(1):41-57. doi: 10.1300/j074v10n01_04. Rooney KL, Domar AD. The relationship between stress and infertility. Dialogues Clin Neurosci. 2018;20(1):41-47. doi: 10.31887/DCNS.2018.20.1/klrooney. Facchin F, Barbara G, Saita E, Erzegovesi S, Martoni RM, Vercellini P. Personality in women with endometriosis: temperament and character dimensions and pelvic pain. Hum Reprod. 2016;31(7):1515-21. doi: 10.1093/humrep/dew108. Grundström H, Larsson B, Arendt-Nielsen L, Gerdle B, Kjølhede P. Pain catastrophizing is associated with pain thresholds for heat, cold and pressure in women with chronic pelvic pain. Scand J Pain. 2020 Jul 28;20(3):635-646. doi: 10.1515/sjpain-2020-0015. Zarbo C, Brugnera A, Frigerio L, Malandrino C, Rabboni M, Bondi E, Compare A. Behavioral, cognitive, and emotional coping strategies of women with endometriosis: a critical narrative review. Arch Womens Ment Health. 2018;21(1):1-13. doi: 10.1007/s00737-017-0779-9. Yosef A, Allaire C, Williams C, Ahmed AG, Al-Hussaini T, Abdellah MS, Wong F, Lisonkova S, Yong PJ. Multifactorial contributors to the severity of chronic pelvic pain in women. Am J Obstet Gynecol. 2016;215(6): 760.e1-760.e14. doi: 10.1016/j.ajog.2016.07.023. Hemmert R, Schliep KC, Willis S, Peterson CM, Louis GB, Allen-Brady K, Simonsen SE, Stanford JB, Byun J, Smith KR. Modifiable life style factors and risk for incident endometriosis. Paediatr Perinat Epidemiol. 2019;33(1):19-25. doi: 10.1111/ppe.12516. Additional Declarations No competing interests reported. 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México","correspondingAuthor":true,"prefix":"","firstName":"Ignacio","middleName":"","lastName":"Camacho-Arroyo","suffix":""}],"badges":[],"createdAt":"2022-06-30 04:44:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1809946/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1809946/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":23723915,"identity":"71b5a5f7-560d-4d7f-a23c-1117bc737ff3","added_by":"auto","created_at":"2022-07-11 18:25:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":203360,"visible":true,"origin":"","legend":"\u003cp\u003ePain perception and emotional dysregulation in endometriosis women with cyclical and non-cyclical chronic pelvic pain. n=49, **p\u0026lt;0.01.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-1809946/v1/7de78eaf030373172d10b9e3.png"},{"id":23723916,"identity":"026bd2a5-1be9-4e7b-93ec-1d9d14c392f6","added_by":"auto","created_at":"2022-07-11 18:25:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":632962,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1809946/v1/4b2a6a91-4134-429d-b71a-1a1119363ab1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Emotional dysregulation in endometriosis women with cyclical and non-cyclical chronic pelvic pain","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEndometriosis is a disease distinguished by a tissue similar to the lining of the uterus growing outside it causing pain and infertility \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. 50% of infertile women exhibit endometriosis worldwide. Therefore, it is considered the most common gynecological disease in women of reproductive age and in perimenopausal women \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. In Mexico, epidemiological reviews have estimated an endometriosis incidence of 34.5% in women diagnosed with primary and secondary infertility at the National Institute of Perinatology \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eEndometriosis symptoms are infertility, dyspareunia, heavy menstrual bleeding, chronic fatigue, fibromyalgia, migraine, and central sensitization syndrome \u003csup\u003e\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. However, the main clinical problem of endometriosis is chronic pelvic pain (CPP), which is defined as intermittent or constant pain in the lower abdomen or pelvis of at least six months, not occurring exclusively with menstruation or intercourse, and not associated with pregnancy \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. One of the most common causes of CPP in women is endometriosis (24\u0026ndash;40%). Other associated conditions such as interstitial cystitis/bladder pain syndrome, chronic urinary tract infections, vulvodynia, irritable bowel syndrome, and inflammatory bowel disease may be comorbid with endometriosis \u003csup\u003e\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eCPP is a persistent and debilitating condition associated with high costs and morbidity. Significant costs are associated with CPP, including absences from work, increased surgeries, and heavy burden to the healthcare system \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. CPP and infertility in women with endometriosis are associated with high levels of stress and uncertainty, reducing their quality of life and making challenging the performance of daily activities and the development of interpersonal relationships \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Additionally, the difficulty experienced by these women from the onset of the first symptoms until diagnosis increases the probability of presenting emotional alterations. The average time between the onset of symptoms and the seeking help is from 3.7 to 5.7 years, extending up to 8 years for timely diagnosis \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe mechanisms by which CPP is generated in endometriosis have not been clearly defined. However, it occurs near endometriotic glands, and blood vessels in peritoneal endometriotic lesions innervated by sensory A delta, sensory C, cholinergic and adrenergic nerve fibers \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Nerve fiber densities are increased in the myometrium of women with endometriosis compared with those presented in women without this pathology \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Although these nerve fibers may play an essential role in the mechanisms of pain generation in endometriosis, the emotional dysregulation can mediate the nociceptive experience by brain regions such as the anterior insula and the anterior cingulate cortex \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eVariable and broad symptoms and social implications of endometriosis have been considered disruptive to mental health, exhibiting high anguish, anxiety, depression, and chronic stress \u003csup\u003e\u003cspan additionalcitationids=\"CR24 CR25\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. It has been described that the presence of CPP affects mental health \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e, regardless of endometriosis stage or type \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e, and it did not always decrease after medical treatment or surgery. Patients with endometriosis may experience CPP cyclically or non-cyclically (80% of cases) defined as non-menstrual pain \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e; however, whether there is a difference in levels of anxiety and depression between these two patient groups has not been evaluated. Therefore, it is not known how different CPP affects the emotional state of women with endometriosis. This study aimed to determine if there are differences in emotional dysregulation in patients with cyclic and non-cyclic CPP.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eDesign of the Study\u003c/h2\u003e\n\u003cp\u003eWe conducted a transversal study at the National Institute of Perinatology\u0026nbsp;(INPer, Neuroscience Department, Mexico City) from January 2019 to March 2020. Approval from the Institution Ethical and Scientific Committee was obtained before the beginning of the study (reference number: INPer, 2019-1-51). Women with endometriosis were invited to participate in the study when coming to their gynecology interview at Department of Gynecology at INPer. Patients who voluntary participated in the study were requested to sign a written informed consent.\u003c/p\u003e\n\u003cp\u003eDuring the initial interviews at the Gynecology and Neuroscience Departments, we assessed the patients\u0026rsquo; eligibility according to the inclusion criteria. Participants gynecological, sociodemographic, and psychological characteristics were recorded in a database.\u003c/p\u003e\n\u003ch2\u003eParticipants\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003ePatients recruited into the study were attended at the Gynecology Department in the INPer. \u0026nbsp;The recruited population comprised women from 18 to 52\u0026thinsp;years old with a diagnosis of endometriosis (by laparoscopic or magnetic resonance) and CPP for at least 1 year. The medical staff carried out a complete clinical evaluation and an analysis of sociodemographic variables was done, including marital status, education level, and working status. Participants were asked to complete self-reported questionnaires used to measure cognitive impairment, the intensity of pelvic pain, general discomfort, depression, and anxiety: Mini-Mental State Examination (MMSE), Visual Analog Scale (VAS), Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI) and Generalized Anxiety Disorder\u0026nbsp;Screener\u0026nbsp;(GAD).\u003c/p\u003e\n\u003cp\u003e54 patients were recruited, but 5 were discarded for not completing evaluations. 49 participants were included in the study and divided into two groups according to the type of CPP they experienced. If the patient suffered from CPP only during her menstrual period, she was classified in the cyclical CPP group (n=21), if the patient presented persistently CPP regardless of the menstrual phase, she was classified in the group of non-cyclical CPP group (n=28).\u003c/p\u003e\n\u003ch2\u003eInstruments\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe Mini-Mental State Examination (MMSE) is a test used to detect mild cognitive impairmentthrough tests of orientation, memory, attention, calculation, and language. If the score is\u0026nbsp;\u0026le;\u0026nbsp;24, probable cognitive impairment is suspected and if it is \u0026gt; 24, the result was \u0026quot;without cognitive impairment\u0026quot; \u003csup\u003e30\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWong-Baker FACES\u0026reg; Pain Rating Scale is a visual analog scale (VAS) that self-reported the intensity of CPP. The scale is made up of six faces drawn with ratings from 0 to 10, where 0 is equivalent to the minimum pain and 10 to the maximum pain that have experienced \u003csup\u003e31\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBeck Depression Inventory (BDI) is a 21-item measure of depression equivalent to the Diagnostic and Statistical Manual of Mental Disorders (DSM) symptoms of depression \u003csup\u003e32\u003c/sup\u003e. Patients chose their responses on a 0-3 Likert-type scale. BDI scores can range from 0 to 63 with the following cut- offs: 0-13, minimally depressed; 14-19, mildly depressed, 20-28, moderately depressed, and 29-63, severely depressed \u003csup\u003e33,34\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eState-Trait Anxiety Inventory (STAI) is used to measure two different dimensions of anxiety: State Anxiety Scale evaluated the current state of anxiety, asking how patients feel \u0026ldquo;right now\u0026rdquo;; and Trait Anxiety Scale evaluated relatively stable aspects of \u0026ldquo;anxiety proneness\u0026rdquo; \u003csup\u003e35\u003c/sup\u003e. Scores of both scales range from 20 to 80. Scores between 20 and 31 indicated minimal anxiety, 32 to 43 mild anxiety, 44 to 55 moderate anxiety, 56 to 67 severe anxiety, and 60 to 80 maximum anxiety\u003csup\u003e36\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGeneralized Anxiety Disorder\u0026nbsp;Screener\u0026nbsp;(GAD) is a 7-item self-report for screening of Generalized Anxiety Disorder which are rated on a 4-point Likert-type indicating symptom frequency, ranging from 0 (not at all sure) to 3 (nearly every day), yielding a value in the response range from 0 to 21 points. Higher scores indicate higher levels of GAD symptoms \u003csup\u003e37\u003c/sup\u003e.\u003c/p\u003e\n\u003ch2\u003eStatistical analysis\u003c/h2\u003e\n\u003cp\u003eDemographic parameters and sociomedical conditions were expressed as mean \u0026plusmn; SD or N (%). Inferential analysis was performed with a chi-square (nominal variables), Mann-Whitney U (ordinal variables), and Student\u0026rsquo;s t-test for independent samples (scalar variables) to compare the difference between groups. Relative risk estimation was performed to determine the association between non-cyclical and cyclical CPP with probability of presenting emotional dysregulation. Statistical analyzes were performed with SPSS v.24.0 software (Armonk, New York: IBM Corp). For all statistical analyses, p \u0026lt; 0.05 was considered significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eDemographics characteristics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 1 shows the sociodemographic characteristics of endometriosis women with cyclical (n=21) and non-cyclical CPP (n = 28). There were no differences in age, years of study, working status and marital status between the two groups. \u0026nbsp;However, results indicate that only 23.8% of women with cyclic pain and 53.5% with non-cyclical pain were married or cohabiting. \u0026nbsp;\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eSociodemographic characteristics of endometriosis women with CPP.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" style=\"border-collapse: collapse; margin: 0px auto;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.11323763955343%\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.358851674641148%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCyclical pain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.199362041467303%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-cyclical pain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.328548644338117%\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.11323763955343%\"\u003e\n \u003cp\u003en=49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.358851674641148%\"\u003e\n \u003cp\u003en=21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.199362041467303%\"\u003e\n \u003cp\u003en=28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.328548644338117%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.11323763955343%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.358851674641148%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.199362041467303%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.328548644338117%\"\u003e\n \u003cp\u003e\u003cstrong\u003e.80\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.11323763955343%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.358851674641148%\"\u003e\n \u003cp\u003e35.2 (6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.199362041467303%\"\u003e\n \u003cp\u003e34.7 (6.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.328548644338117%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.11323763955343%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.358851674641148%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.199362041467303%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.328548644338117%\"\u003e\n \u003cp\u003e\u003cstrong\u003e.10\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.11323763955343%\"\u003e\n \u003cp\u003eNever married\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.358851674641148%\"\u003e\n \u003cp\u003e15 (71.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.199362041467303%\"\u003e\n \u003cp\u003e10 (35.7)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.328548644338117%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.11323763955343%\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.358851674641148%\"\u003e\n \u003cp\u003e3 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.199362041467303%\"\u003e\n \u003cp\u003e9 (32.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.328548644338117%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.11323763955343%\"\u003e\n \u003cp\u003eDivorced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.358851674641148%\"\u003e\n \u003cp\u003e1 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.199362041467303%\"\u003e\n \u003cp\u003e3 (10.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.328548644338117%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.11323763955343%\"\u003e\n \u003cp\u003eCohabiting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.358851674641148%\"\u003e\n \u003cp\u003e2 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.199362041467303%\"\u003e\n \u003cp\u003e6 (21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.328548644338117%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.11323763955343%\"\u003e\n \u003cp\u003e\u003cstrong\u003eYears of study\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.358851674641148%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.199362041467303%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.328548644338117%\"\u003e\n \u003cp\u003e\u003cstrong\u003e.40\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.11323763955343%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.358851674641148%\"\u003e\n \u003cp\u003e14.4 (3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.199362041467303%\"\u003e\n \u003cp\u003e15.1 (3.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.328548644338117%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.11323763955343%\"\u003e\n \u003cp\u003e\u003cstrong\u003eWorking status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.358851674641148%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.199362041467303%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.328548644338117%\"\u003e\n \u003cp\u003e\u003cstrong\u003e.96\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.11323763955343%\"\u003e\n \u003cp\u003eEmployee\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.358851674641148%\"\u003e\n \u003cp\u003e5 (23.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.199362041467303%\"\u003e\n \u003cp\u003e5 (17.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.328548644338117%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.11323763955343%\"\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.358851674641148%\"\u003e\n \u003cp\u003e2 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.199362041467303%\"\u003e\n \u003cp\u003e4 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.328548644338117%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.11323763955343%\"\u003e\n \u003cp\u003eHome labor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.358851674641148%\"\u003e\n \u003cp\u003e5 (23.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.199362041467303%\"\u003e\n \u003cp\u003e7 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.328548644338117%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.11323763955343%\"\u003e\n \u003cp\u003eCommerce\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.358851674641148%\"\u003e\n \u003cp\u003e3 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.199362041467303%\"\u003e\n \u003cp\u003e4 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.328548644338117%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.11323763955343%\"\u003e\n \u003cp\u003eProfession\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.358851674641148%\"\u003e\n \u003cp\u003e4 (19.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.199362041467303%\"\u003e\n \u003cp\u003e6 (21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.328548644338117%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.11323763955343%\"\u003e\n \u003cp\u003eStudy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.358851674641148%\"\u003e\n \u003cp\u003e1 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.199362041467303%\"\u003e\n \u003cp\u003e2 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.328548644338117%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.11323763955343%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.358851674641148%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.199362041467303%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.328548644338117%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe parametric t-test was used to detect statistical differences between demographic measures age, years of study. The chi-square test was used to determine differences in marital status, working status between women with cyclical and non-cyclical pain. n=49.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Medical characteristics of patients are described in Table 2. The percentage of nulliparous women is higher in women with non-cyclical CPP (78.6%) than in cyclical CPP women (45.6%). In both cases about 60% of patients report disabling pain for about 11 years and more than 70% of all women described at least another symptom associated with endometriosis. Most patients in both groups have received at least one surgery to manage symptoms including cleaning of endometrial focuses by laparoscopy, which was the most common surgery in these patients. Additionally, all women reported consumption of some drug for the endometriosis symptoms, mainly non-steroidal anti-inflammatory drugs (NSAIDs). This consumption was significantly higher in women with non-cyclical pain (92.9 %) compared with cyclical CPP women (71.4 %). Differences in comorbidities were found, the percentage of women with hypothyroidism and myomatosis was higher in women with cyclical CPP compared to women with non-cyclical CPP. No differences were found in disabling CPP perception, years reporting disabling pain, other presenting symptoms, previous surgery endometriosis, or disruptions, between women with cyclical and non-cyclical pain. \u0026nbsp;\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003e\u0026nbsp;Medical conditions of endometriosis women with CPP.\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp style=\"text-align: left;\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCyclical pain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-cyclical pain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.49282296650718%\"\u003e\n \u003cp\u003e\u003cstrong\u003eParity\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48803827751196%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.169059011164276%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eNulliparous\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e10 (45.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e22 (78.6) *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003e\u0026ge;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e11 (52.4) *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e6 (21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eInfertility diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e2 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.49282296650718%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisabling CPP\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eperception\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48803827751196%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.169059011164276%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.850079744816586%\"\u003e\n \u003cp\u003e\u003cstrong\u003e.61\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e12 (57.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e18 (64.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e9 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e10 (35.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.49282296650718%\"\u003e\n \u003cp\u003e\u003cstrong\u003eYears reporting disabling CPP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48803827751196%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.169059011164276%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.850079744816586%\"\u003e\n \u003cp\u003e\u003cstrong\u003e.69\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e10.8 (1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e11.6 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.49282296650718%\"\u003e\n \u003cp\u003e\u003cstrong\u003eOther symptoms\u003csup\u003e\u0026nbsp;a\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48803827751196%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.169059011164276%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eNo other \u003csup\u003eb\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e\u003cstrong\u003e7 (\u003c/strong\u003e33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e7 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.52\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eMenorrhagia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e6 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e14 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eDyspareunia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e7 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e10 (35.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eWidespread pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e2 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e4 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.61\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eAmenorrhea\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e2 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e3 (10.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.89\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eChronic fatigue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e1 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e4 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eInflammation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e4 (19.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e1 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eRectal tenesmus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e0\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e2 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eDysuria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e1 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e1 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.83\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003ePremenstrual dysphoria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e1 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eSubinfertility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e1(4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.73\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.49282296650718%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrevious endometriosis surgery\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48803827751196%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.169059011164276%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.850079744816586%\"\u003e\n \u003cp\u003e\u003cstrong\u003e.84\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e6 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e8\u0026nbsp;(28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e9 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e10 (35.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003e\u0026ge;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e6 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e10 (35.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.49282296650718%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgery for endometriosis\u003csup\u003ea\u003c/sup\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48803827751196%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.169059011164276%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eEndometrial focuses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e5 (23.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e13 (46.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.52\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eOophorectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e6 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e5\u0026nbsp;(17.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eHysterectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e3 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e5 (17.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.73\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eColectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e2 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e1 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.49282296650718%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePharmacotherapy\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48803827751196%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.169059011164276%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.49282296650718%\"\u003e\n \u003cp\u003eNSAIDs \u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48803827751196%\"\u003e\n \u003cp\u003e15 (71.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.169059011164276%\"\u003e\n \u003cp\u003e26 (92.9) *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.49282296650718%\"\u003e\n \u003cp\u003eHormones\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48803827751196%\"\u003e\n \u003cp\u003e7 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.169059011164276%\"\u003e\n \u003cp\u003e8 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.72\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.49282296650718%\"\u003e\n \u003cp\u003eAntispasmodic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48803827751196%\"\u003e\n \u003cp\u003e1 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.169059011164276%\"\u003e\n \u003cp\u003e3 (10.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.49282296650718%\"\u003e\n \u003cp\u003eAnxiolytics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48803827751196%\"\u003e\n \u003cp\u003e2 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.169059011164276%\"\u003e\n \u003cp\u003e2 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.76\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.49282296650718%\"\u003e\n \u003cp\u003eOpioid analgesic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48803827751196%\"\u003e\n \u003cp\u003e2 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.169059011164276%\"\u003e\n \u003cp\u003e1 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.49282296650718%\"\u003e\n \u003cp\u003eCannabis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48803827751196%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.169059011164276%\"\u003e\n \u003cp\u003e2 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.49282296650718%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eDisruptions\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48803827751196%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.169059011164276%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e9 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e5 (17.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eWork/School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e5 (23.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e10 (35.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eRelationship\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e6 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e8 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eNext surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e5 (23.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e6 (21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.84\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eSocial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e3 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e5 (17.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.73\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eDesire to be a mother\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e3 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e4 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eFamily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e5 (17.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eEconomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"22.48803827751196%\"\u003e\n \u003cp\u003e1 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"22.169059011164276%\"\u003e\n \u003cp\u003e1 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.83\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.49282296650718%\"\u003e\n \u003cp\u003e\u003cstrong\u003eComorbidities\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48803827751196%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.169059011164276%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48803827751196%\"\u003e\n \u003cp\u003e10 (47.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.169059011164276%\"\u003e\n \u003cp\u003e19 (67.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003ePolycystic ovary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48803827751196%\"\u003e\n \u003cp\u003e3 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.169059011164276%\"\u003e\n \u003cp\u003e3 (10.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eHypothyroidism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48803827751196%\"\u003e\n \u003cp\u003e3 (14.3) *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.169059011164276%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eMyomatosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48803827751196%\"\u003e\n \u003cp\u003e3 (14.3) *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.169059011164276%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eAdenomyosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48803827751196%\"\u003e\n \u003cp\u003e2 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.169059011164276%\"\u003e\n \u003cp\u003e1 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eOveractive bladder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48803827751196%\"\u003e\n \u003cp\u003e2 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.169059011164276%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eObesity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48803827751196%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.169059011164276%\"\u003e\n \u003cp\u003e1 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eAnemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48803827751196%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.169059011164276%\"\u003e\n \u003cp\u003e1 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.49282296650718%\"\u003e\n \u003cp\u003eHeart disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.48803827751196%\"\u003e\n \u003cp\u003e1 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.169059011164276%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.850079744816586%\"\u003e\n \u003cp\u003e.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003eThe parametric t-test was used to detect statistical differences between years reporting disabling CPP. The chi-square test was used to determine differences disabling CPP, parity, other presenting symptoms, previous surgery for endometriosis, pharmacotherapy, disruptions, and comorbidities between women with cyclical and non-cyclical pain.\u003c/em\u003e \u003cem\u003en=\u003c/em\u003e\u003cem\u003e49; *p\u0026lt;0.05. (a) Different options can be associated in the same patient. (b) No other symptoms of endometriosis besides CPP. (c) NSAIDs, Non-steroidal anti-inflammatory drugs.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTo determine differences in global scores psychometric scales applied between endometriosis patients with cyclical and non-cyclical CPP, a normal distribution of the results was corroborated with the Shapiro wilk test for n \u0026ge; 30 and Levene\u0026apos;s test showed equality of variances. Then, the global scores of each scale were analyzed using a Student\u0026apos;s t test for independent samples. The global scores obtained in depression, anxiety as a trait and state, and generalized anxiety were higher in women with non-cyclical chronic pain than in those with cyclical pain (Table 3). Student\u0026apos;s t test for cognitive impairment could not be calculated because the standard deviation of both groups was equal to 0.\u0026nbsp;\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003e\u0026nbsp;Cognitive impairment, pain perception, and emotional dysregulation global scores in endometriosis women with cyclical and non-cyclical pain.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable align=\"\" border=\"1\" cellpadding=\"0\" cellspacing=\"0\" style=\"border-collapse: collapse; margin: 0px auto;\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of chronic pelvic pain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCyclical\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNon-cyclical\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\"\u003e\n \u003cp\u003eCognitive impairment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\"\u003e\n \u003cp\u003e28.80 (1.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;28.35 (1.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\"\u003e\n \u003cp\u003e.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\"\u003e\n \u003cp\u003ePain intensity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\"\u003e\n \u003cp\u003e\u0026nbsp; 7.90 (2.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\"\u003e\n \u003cp\u003e8.85 (1.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003e.13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\"\u003e\n \u003cp\u003e11.14 (2.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\"\u003e\n \u003cp\u003e17.46 (1.92) *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003e.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\"\u003e\n \u003cp\u003eTrait anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\"\u003e\n \u003cp\u003e37.42 (3.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;47 (2.02) *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003e.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\"\u003e\n \u003cp\u003eState anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\"\u003e\n \u003cp\u003e39.33 (2.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\"\u003e\n \u003cp\u003e47.35 (1.89) *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003e.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\"\u003e\n \u003cp\u003eGeneralized anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\"\u003e\n \u003cp\u003e\u0026nbsp; 5.14 (1.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\"\u003e\n \u003cp\u003e\u0026nbsp; 8.46 (1.05) *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003e.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style=\"text-align: center;\"\u003e\u0026nbsp;Table shows the mean \u0026plusmn; SD, n=49, *p\u0026lt;0.05.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo determine differences in pain perception and emotional dysregulation between patients with cyclical and non-cyclical CPP according to the clinical classification of each psychometric scales, a Mann-Whitney U test was performed. Most patients with non-cyclical pelvic pain exhibited mild state anxiety (\u0026alpha; = 0.007) and depression from mild to severe (\u0026alpha; = 0.018) compared to women with cyclical CPP that presented a lower emotional affectation (Figure 1). No differences were observed in pain intensity, anxiety as a trait or generalized anxiety according to the clinical classification. However, it was found that 70% of endometriosis women with cyclical CPP and more than 90% of the non-cyclical population reported severe to maximum pain; and more than 60% of patients with noncyclic pain presented mild to severe generalized anxiety.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA relative risk estimation was performed to determine the association between non-cyclical or cyclical CPP and the probability of presenting depression or anxiety as risk factors. Results demonstrated a significant relative risk (\u0026gt; 1) in depression (2.5), trait-state anxiety (2.25, 2.85, respectively), and generalized anxiety (2.0) in patients with non-cyclical pain. Relative risk of patients with cyclical chronic pain was not significant (Table 4).\u0026nbsp;\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cstrong\u003eRelative risks of patients with cyclical and non-cyclical pain\u003c/strong\u003e\u003c/p\u003e\n\u003ctable align=\"\" border=\"0\" cellpadding=\"0\" cellspacing=\"0\" style=\"border-collapse: collapse; margin: 0px auto;\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"13.385826771653543%\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of chronic pain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"18.74015748031496%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDepression\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"12.913385826771654%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTrait anxiety\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.456692913385826%\"\u003e\n \u003cp\u003e\u003cstrong\u003eState anxiety\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"28.503937007874015%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGeneralized anxiety\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"13.385826771653543%\"\u003e\n \u003cp\u003eCiclycal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"18.74015748031496%\"\u003e\n \u003cp\u003e0.40 (0.13-1.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"12.913385826771654%\"\u003e\n \u003cp\u003e0.44 (0.17-1.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.456692913385826%\"\u003e\n \u003cp\u003e0.35 (0.6-0.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"28.503937007874015%\"\u003e\n \u003cp\u003e0.54 (0.28-1.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" width=\"13.385826771653543%\"\u003e\n \u003cp\u003eNon-cyclycal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"18.74015748031496%\"\u003e\n \u003cp\u003e2.5 (0.82-7.54) *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"12.913385826771654%\"\u003e\n \u003cp\u003e2.25 (0.88-5.71) *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"26.456692913385826%\"\u003e\n \u003cp\u003e2.85 (1.29-6.25) *\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" width=\"28.503937007874015%\"\u003e\n \u003cp\u003e2.0 (0.96-3.45) *\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable shows relative risk scores and SD, asterisk (*) represents a significant relative risk (\u0026gt; 1). \u0026nbsp;n=49.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eEndometriosis is a long-term, disabling medical condition that affects the quality of life and mental health associated with CPP. Patients with endometriosis may experience CPP in a cyclical manner such as dysmenorrhea or in a noncyclical manner defined as non-menstrual pain. Several reports suggest that chronic experience of pain increases emotional dysregulation \u003csup\u003e\u003cspan additionalcitationids=\"CR39\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e and that psychiatric disorders are more common among women with endometriosis \u003csup\u003e\u003cspan additionalcitationids=\"CR42 CR43\" citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e, however, differences in emotional dysregulation based on CPP experience in women with endometriosis had not been explored. Therefore, the objective of this study was to determine if there are differences in the levels of emotional dysregulation in patients with cyclical and non-cyclical CPP. This is one of the few studies carried out in Latin America where specialized endometriosis care centers are very limited \u003csup\u003e\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eHigh levels of depression and anxiety were found in both groups of patients with CPP, which coincided with previous studies \u003csup\u003e\u003cspan additionalcitationids=\"CR42 CR43\" citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e, however, the present work is the first one in demonstrating higher global scores in depression, anxiety as a trait and state, and generalized anxiety in women with non-cyclical CPP. In addition, more women with endometriosis experiencing non-cyclic CPP suffered from mild to severe depression and mild state anxiety compared to women experiencing cyclical pain. Therefore, emotional attention of these women is imperative to improve their quality of life. Relative risk estimation associated with pain intensity determined a higher probability of developing depression, trait-state anxiety, and generalized anxiety in patients with non-cyclical pain. In fact, the risk of presenting emotional disturbances is doubled in the group of women with noncyclic pain than in those with cyclical pain, which gives us clinically significant and relevant data for the diagnosis and management of these patients \u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e,\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePain intensity was assessed using the VAS, since it has been shown to be effective for most patients with endometriosis (64%) during the painful experience and indeed, one month after the experience \u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e. However, no statistically significant differences were found in intensity of pain between CPP groups. In both cases most patients report severe to maximum pain and perceive it as a disabling pain for about a decade, which could significantly affect their quality-of-life \u003csup\u003e\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e. The relationship between reports of pain and physical pathology is still debated. Authors suggest a complete evaluation of the pain considering location, duration, sensory and affective description, functional status in daily activities \u003csup\u003e\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/sup\u003e; and the hours or sleep disturbances derived from pain \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. Besides, Api \u003csup\u003e\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u003c/sup\u003e highlights that other symptoms of endometriosis such as painful intercourse or dyspareunia can mediate the intensity of CPP; however, in this study no differences were found in other symptoms of endometriosis between patients with cyclical and non-cyclical pain.\u003c/p\u003e \u003cp\u003eFor the management of endometriosis symptoms, all the patients reported drug use, mainly analgesics. Because cognitive impairment is common in patients with chronic pain for excessive use of analgesics including opioids, increased vulnerability to endocrine disrupting chemicals, and age-related cognitive decline \u003csup\u003e\u003cspan additionalcitationids=\"CR53\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u003c/sup\u003e, MMSE test was applied. However, no cognitive impairment was found in women with endometriosis using MMSE. Nevertheless, cognitive impairments were reported by Wassink,\u003csup\u003e\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u003c/sup\u003e through EGG and event-related potentials in these patients. It is recommended to explore specific cognitive functions with neuropsychological batteries to improve rehabilitation for future studies \u003csup\u003e\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn this study, most patients reported disruptions associated with symptoms of endometriosis, at work, relationships and family. In addition, it was observed that most women with cyclical pain had not been married, and most women with non-cyclical pain do not have children. Low social support and family networks must maintain depressive and anxious states \u003csup\u003e\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u003c/sup\u003e, so women with endometriosis may be more vulnerable to living with chronic emotional dysregulation, which is associated with low quality of life \u003csup\u003e\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e. Marital status and number of children are not predictors of emotional well-being in midlife in women, but rather the quality of relationships \u003csup\u003e\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e,\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e\u003c/sup\u003e. Intensity of pain and emotional dysregulation in women with endometriosis can be mediated by psychosocial variables such as emotional suppression, pain catastrophism, personality, and a passive coping style, which can also affect patients\u0026rsquo; interactions \u003csup\u003e\u003cspan additionalcitationids=\"CR62\" citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eDifferent comorbid conditions have been implicated in CPP in endometriosis, such as pelvic floor tenderness, painful bladder syndrome, sexual assault, higher body mass index, current smoking, physical activity, depression, and anxiety \u003csup\u003e\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e\u003c/sup\u003e. This is the first study that describes differences in emotional dysregulation according to the type of CPP experienced by patients with endometriosis. Therefore, continued research is required to validate these psychosocial factors and determine if any of them is potentially modifiable for improving the quality of life of women with endometriosis.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur data suggest that patients with non-cyclical CPP present higher levels of depression and anxiety than those with cyclical pain, and that non-cyclical CPP may make patients more vulnerable to developing emotional dysregulation.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCPP chronic pelvic pain; INPer, National Institute of Perinatology; MMSE, Mini-Mental State Examination; VAS, Visual Analog Scale; BDI, Beck Depression Inventory; DSM, Diagnostic and Statistical Manual of Mental Disorders; STAI, State-Trait Anxiety Inventory; GAD, Screener; NSAIDs, Non-steroidal anti-inflammatory drugs.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eWe received the approval of the clinical study from the head of the Ethical and Research Committee of National Institute of Perinatology, Isidro Espinosa de los Reyes, (Montes Urales # 800, Col Lomas de Virreyes, 11000, CD MX, Mexico) with the project No. 20191-51. The written Informed Consent was also obtained from all participants recruited in the present study All methods were performed in accordance with the relevant guidelines and regulations in compliance with the Helsinki Declaration.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due institutional policies but are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing financial and non-financial interests that could influence the publishing of the final version of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis study was supported by INPer Project No. 2019-1-51, and by CONACYT for the first author\u0026apos;s doctoral grant, No. 749741.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/h2\u003e\n\u003cp skip=\"true\"\u003eMPMR designed and conducted the study. DCRL wrote the body of the manuscript. ICA and BDT were major contributors in reviewing the data and body of the manuscript and amending several areas of the manuscript. \u0026nbsp;OPCO, BSR, AOO, JRST, GCB, LFEP conducted the clinical intervention in women with endometriosis to assesses the recruitment of patients into the study. DCRL and MPMR applied and scored the psychometric instruments to the participants. DCRL, MPMR and JMSP contributed to the statistical analysis of data.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eThis study was supported by INPer Project No. 2019-1-51, and by CONACYT for the first author\u0026apos;s doctoral grant, no. 749741.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eSurrey E, Carter CM, Soliman AM, Khan S, Di Benedetti DB, Snabes MC. Patient-completed or symptom-based screening tools for endometriosis: a scoping review. 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Paediatr Perinat Epidemiol. 2019;33(1):19-25. doi: 10.1111/ppe.12516.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Chronic pelvic pain, anxiety, depression, endometriosis, menstrual cycle, emotions ","lastPublishedDoi":"10.21203/rs.3.rs-1809946/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1809946/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eEndometriosis is a pathophysiological condition characterized by glands and stroma outside the uterus in regions such as the bladder, ureter, fallopian tubes, peritoneum, ovaries, and even in extra pelvic sites. One of the main clinical problems of endometriosis is chronic pelvic pain (CPP), which considerably affects the patients’ quality of life. Patients with endometriosis may, cyclically or non-cyclically (80% of cases) experience CPP. High levels of anxiety and depression have been described in patients with endometriosis related to CPP; however, this has not been evaluated in endometriosis women with different types of CPP. \u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eThis work aimed to determine if there are differences in emotional dysregulation in patients with cyclical and non-cyclical CPP. 49 women diagnosed with endometriosis presenting cyclical and non-cyclical CPP answered several batteries made up of Mini-Mental State Examination, Visual Analog Scale, Beck´s Depression Inventory, State Trait-Anxiety Inventory, and Generalized Anxiety Inventory.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e \u003c/p\u003e\u003cp\u003eWe observed that patients with non-cyclical CPP exhibited higher levels of depression and anxiety (trait-state and generalized anxiety) than patients with cyclical pain. No differences were observed in pain intensity, but there was a higher probability of developing emotional dysregulation (anxiety or depression) in patients with non-cyclical CPP. No differences were observed in cognitive impairment. \u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eOur data suggest that patients with non-cyclical CPP present a higher emotional dysregulation than those with cyclical pain.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Emotional dysregulation in endometriosis women with cyclical and non-cyclical chronic pelvic pain","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-07-11 18:25:27","doi":"10.21203/rs.3.rs-1809946/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-09-26T04:21:10+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-09-21T13:34:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-08-11T12:38:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"75421635-5d68-46e1-9cd1-ed682d8e7af9","date":"2022-07-21T02:50:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1118356f-3421-4a6c-893f-179a7e865481","date":"2022-07-18T07:27:00+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-07-16T16:04:48+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-07-07T21:55:07+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-07-04T05:35:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-07-04T05:32:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2022-06-30T04:42:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"95b56708-9b1f-42cf-90c8-c3315ca23538","owner":[],"postedDate":"July 11th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2022-11-11T12:14:14+00:00","versionOfRecord":[],"versionCreatedAt":"2022-07-11 18:25:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1809946","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1809946","identity":"rs-1809946","version":["v1"]},"buildId":"2u56kwukJI3zHK-uzyFNs","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}